1) You are assigned four patients. Who should the nurse see first? a) Patient with DVT history and SpO₂ of 88% b) Patient with a stage 3 pressure ulcer and pain 7/10 c) Patient recently diagnosed with skin cancer d) Patient with partial burns and pain 8/10 2) Which respiratory rate in an adult patient requires immediate follow-up? a) 22 breaths/min b) 14 breaths/min c) Irregular rate between 16–20 d) 30 breaths/min with increased work of breathing 3) A capillary refill time of 5 seconds is a sign of a) Peripheral arterial disease (PAD) b) Peripheral neuropathy c) Poor tissue perfusion d) Hypocalcemia 4) Which finding in a patient with heart failure requires the most immediate follow-up? a) Shortness of breath while lying flat and crackles in lungs b) Weight gain of 1 kg in 24 hours c) Heart rate 95 bpm d) New onset of mild ankle swelling 5) A patient with a head injury presents with increased systolic blood pressure (widening pulse pressure), a decreasing pulse rate, an irregular respiratory pattern, and unequal pupils. What does this indicate? a) Increased intracranial pressure b) Sedation effect c) Pain response d) Sleep deprivation 6) Which neurological change requires the most urgent follow-up? a) Mild, generalized headache b) Slight difficulty finding words when speaking c) Sudden one-sided facial droop and weakness d) New droopy eyelid on one side 7) During assessment, a patient’s skin is cool, pale, and mottled below the knees. Pulse is rapid. This may indicate a) Peripheral arterial disease b) Shock with poor perfusion c) Neurogenic shock d) Allergic reaction 8) The most urgent finding for a post-partum patient who delivered four hours ago is a) Perineal pad saturated with blood in less than 15 minutes and a boggy (soft) fundus. b) Lochia (vaginal discharge) that is rubra (bright red) and moderate. c) A pulse rate of 98beats/minute. d) Fundus firm and located below the umbilicus. 9) A patient receiving IV antihypertensive medication suddenly has a systolic BP below 90 mmHg. What should the nurse do? a) Note mild nausea b) Stop the infusion and notify the provider c) Continue and recheck in 30 minutes d) Let the patient rest 10) A patient with cirrhosis and ascites is suddenly more agitated and confused. These findings most urgently indicate a) Delirium tremens from alcohol withdrawal. b) Severe hypoglycemia. c) Acute onset of dehydration. d) Hepatic encephalopathy due to high ammonia levels.

Nursing Findings That Require Immediate Follow-Up

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